APPLICATION FOR EMPLOYMENT Application must be completed in its entirety. Please print clearly.

Transcription

1 Rev. 01/2017 v Seabury Drive Bloomfield, CT APPLICATION FOR EMPLOYMENT Application must be completed in its entirety. Please print clearly. SEABURY IS A DRUG & ALCOHOL FREE WORKPLACE. ALL APPLICANTS ARE REQUIRED TO SUBMIT TO A PRE-EMPLOYMENT DRUG SCREEN & BACKGROUND CHECK AS A CONDITION OF EMPLOYMENT. (initials) PERSONAL INFORMATION Name Last First M.I. Date: Previous Name(s): Present Address: Street City, State Zip Code Previous Address: Street City, State Zip Code Phone (Days Cell Are you legally eligible for employment in the USA? State age if under 18 Position(s) applied for Rate of pay expected $ /per hour Would you prefer to work: Full time Part-time Specify days and hours of part-time Shift(s) preferred: Available for overtime? Were you previously employed by us? If yes, please list your position, dates of employment and the reason you left: If your application is considered favorably, on what date will you be available to begin work?, 20 Are there any other experiences, skills, or qualifications, which you feel, would especially fit you for work with our organization? Do you have a commitment to another employer (i.e., employment contract, layoff/recall status)? If yes, please specify details:

2 EDUCATION Please provide information regarding your educational background (i.e., schools attended, degrees received), and any other information that may be useful in considering your application for employment. Level of Education Name/Address of School Last Year Completed College Did You Graduate? Course of Study Grade point average Diploma/ Degree Rec d Other High School Technical Are you currently enrolled in a course? If yes, please describe: EMPLOYMENT HISTORY Please list below your employment record beginning with your PRESENT or most recent position. If you are currently employed, please be assured that your employer will not be contacted without your permission. Employer s Name Describe your job responsibilities: )

3 Employer s Name Employer s Name Employer s Name

4 Please account for any period of time not covered in your employment or educational record. Have you ever been terminated from a position, asked to resign or left a job without notice? If yes, please explain Is there any person/organization listed in your employment history that you do not want us to contact? If yes, please indicate name and reason MILITARY RECORD Are you now or have you ever been a member of the United States Armed Forces? If yes, which branch of service? Dates of duty: / / Rank at discharge: PROFESSIONAL REFERENCES Note students please use teachers or guidance personnel List 3 professional references and state relationship to you, i.e. former manager, colleague, teacher, etc. Name Occupation Relationship to you Telephone If you were referred by a Seabury employee, please state their name and how you know them: Please list the names of any relatives presently employed by Seabury

5 Applicant s Statement Church Home of Hartford, Inc., d/b/a Seabury, is an equal opportunity employer and does not discriminate as to age, race, color, creed, marital status, sex, national origin, sexual orientation, disability or other protected status under state and federal laws. I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment, related papers or oral interviews as may be necessary in arriving at an employment decision. If I have applied for a position deemed to be safety-sensitive, I give permission for Seabury to conduct related credit investigations. I understand Seabury has the right and duty to solicit certain CDL-related drug and alcohol testing information from prior employers. I consent to take a medical examination by a qualified physician at the discretion of my employer. I further understand that this is an application for employment and no employment is being offered. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this at will employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand I am required to abide by all rules and regulations of the employer. Signature of Applicant Date Print Name